Presenting a case of a robotic eTEP access Rives-Stoppa of the left TAR with retromuscular modified Sugarbaker Pauli repair of a complex hernia.
Patient is a 31-year-old female with a history of colonic inertia and pelvic floor dysfunction, who underwent a total colectomy, permanent ileostomy. She had a 6-cm midline incisional hernia that was repaired in November of 2021 with the Symbotex 10 by 15 mesh. Shortly, thereafter, she had a 6-centimeter defect with the seroma. She also had a parastomal component with small bowel herniating, although the fascial defect around the stoma was normal-sized.
Began the surgery with a 5-millimeter optical entry in the left upper quadrant, right under the costal margin with simultaneous insufflation, developing the retromuscular space on the left side in a standard fashion. Did encounter some bleeding and adhesions due to the previous hernia repair, so I used the LigaSure to control bleeding from those perforators and use that to continue developing the space and place three robotic 8-millimeter trocars on the left side.
Here, you can see some of the clots from that bleeding, which I eventually suctioned. Incision of the left posterior rectus sheath, exposing the preperitoneal fat behind the falciform. You can see my access site here, which I eventually turn into a 12-millimeter assist port to pass the mentioned sutures. Working my way towards the contralateral posterior rectus sheath. Incision of the right posterior rectus sheath, exposing the right rectus muscle and entering the right retromuscular space. Developing the right retromuscular space, working my way down towards the hernia defect.
Here, the sac was entered, and you can see evidence of the previous mesh and the previous hernia repair. Here is after the hernia was reduced and working my way down below the hernia into the space of Retzius and completion of the division of the posterior rectus sheath. Dissection down into the space of Retzius and Cooper’s ligament. Here’s the dissection around the stoma.
You can see some of the parastomal component there. Then, a bottoms-up TAR was started heading towards the stoma.
Then, a top-down TAR to meet the stoma also. Here’s the division of the trans abdominis muscle, working down to towards the stoma. Here’s completion of the [inaudible 00:04:29]. Using the assistant trocar here to help me retract the stoma and lyse adhesions and reduce the bowel. After complete lysis of adhesions, the posterior sheath was incised to lateralize the stoma. And then the stoma was lateralized all the way down, and just showing some of the sutures that were placed.
This is closure of the posterior sheath medial to the stoma. Then I took some interrupted sutures circumferentially to tack the stoma to the peritoneum to prevent herniation. We can use the Vicryl figure of eight sutures for that. Then I closed the posterior sheath and peritoneum.
And I measured the retromuscular space and planned for a slit around the stoma. Here, you can see the hernia defect that measured 6 centimeters with seroma. Seroma was drained, and the anterior fascia closed.